0109-157 (RR)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O M M License # Lic. Class Exp. Date
oZ I— Date Signature of Contractor
�Oti
J U C:) OWNER -BUILDER DECLARATION
HLU r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Cn License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
('•;) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co () I am exempt,under Section B&P.C. for this reason
LO er on , , .
O N Date Signature of Owner
N
CL z WORKER'S COMPENSATION DECLARATION
o < cr I hereby affirm under penalty of perjury one of the following declarations:
U*) F2 O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
ED Q O ( ) I have and will maintain workers' compensation insurance, as required by
O � Q Section 3700 of the Labor Code, for the performance of the work for which this
0)— permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier Policy No.
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J (This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal pe,ialties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT
PERMIT#
DATE VALUATION LOT
; ! t';' j ;=•.._
TRACT
'1 'i-.t'f,,,ik;:
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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CA 92201
MAIN 5 DIF
USE OF PERMIT
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SEP 1 8 2001
L�[
CITY OF LA QUINTA
FINANCE DEpr.
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RECEIPT
DATE J
BY
DATE FINALED
INSPECTOR
+
INSPECTION RECORD
OPERATION DATE INSPECTOR
OPERATION DATE I INSPECTOR
BUILDING APPROVALS I
MECHANICAL APPROVALS
Set Backs I
Underground Ducts
Forms & Footings
Ducts
Slab Grade
I
Return Air
Steel
Combustion Air
!_
I
Roof Deck
Exhaust Fans
O. —to wrap
I
F.A.U. I
- —
Framing Compressor [
—
Insulation Vents I I
Fireplace P.L. ! Grills
Fireplace T.O. [ Fans & Controls
Party 1-1 ns u —lation I Condensate Lines —
Party Wall Firewall
Exterior Lath I 1
D va11- In'. Lath_ f
ildl
j Fina! �I
Final J�I2��d� - POOLS -SPAS
BLOC, Klvv� Steel
Set I acks Electric Bond
Fi7c,NITM,
Main Drain
Bond Seam - - _
—[ I Approval to Cover I
_ _ �[
_ T Equipment Location i I -
Underground Elcotric 1— — •_
-
Underground P Iq. Test _� I _ [
- -
Final ` I Gas Piping
- —� - - —I-
I Gas Test
I-`LUMISING
,PPR0VALS f Electric Final {t !
Waste Lines — - .j�
� �� Heater Fina!
Nater Piping I Plumbing Final
_
Plumbing Top Out _ f _ _ _ I� I Equipment Enclosure
Shower Pans OX for Finish Plaster
Sewer Latera! — - — —� - — — - -�^
, Pool Cover
_ _ _
Sewer Connection Encapsulation
Gas Piping I j
Gas Test
Appliances
Final I
COMMENTS:
Final
Utility Notice (Gas)
-
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
!
Rough wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)